The proliferation of health care providers marketing themselves as board-certified physicians specializing in dermatology, non-physicians performing medical aesthetic procedures, and nurses and others calling themselves “doctor” after obtaining doctoral degrees are all reasons why some dermatologists have been pushing for state legislation that promotes transparency.

Although states have taken various approaches, the goal is the same: requiring providers to disclose their qualifications. Patient safety is at the core of the issue, advocates for the laws say. Dermatologists are seeing a growing number of individuals who have suffered adverse events as well as missed or misdiagnosed skin cancers at the hands of non-physicians and/or physicians who have limited or no formal training or education in aesthetic medicine or dermatology.

“We can’t sit on the sidelines and watch as our patients are snookered by people who claim to have all this training that they don’t. We need to stomp out the fraud,” said Trent Massengale, MD, a dermatologist who was involved in getting a truth in advertising law passed in Louisiana.

Misleading advertising

False or misleading advertising of medical services comes in various forms. Among them are an ad that promotes a board-certified physician “specializing in dermatology” who heads a dermatology clinic that neither discloses that the physician is not board-certified in dermatology nor identifies the field in which the physician is board-certified. Other ads indicate that a physician is board certified, but do not note that the board is not one recognized by the American Board of Medical Specialties. These ads purposely use the term “board-certified physician” to confuse consumers who don’t necessarily know that a board-certified physician specializing in dermatology is not the same as a board-certified dermatologist, noted Kathryn Chandra, the American Academy of Dermatology Association’s assistant director of state policy.

Another example is an ad that touts a health care provider as “an expert in skin care” without identifying the credentials of the provider. This commonly occurs in ads for medical spas that offer a range of services, including laser hair removal, intense pulsed light treatments, microdermabrasion, chemical peels, and filler and botulinum toxin injections. Patients often assume that these cosmetic services are being delivered by a physician or a health care professional with physician oversight, but that is often not the case, said Cindy Firkins Smith, MD, a dermatologist practicing in Willmar, Minn., who is working to pass legislation in her state.

All of these ads mislead consumers into believing that the providers are dermatologists by neglecting to clearly identify their training and credentials, Chandra added. [pagebreak]

Just call me doctor

Additionally, a growing number of mid-level providers are pursuing non-physician doctoral degrees, noted Kimberly Cayce, MD, president of the Missouri Dermatological Society.

The American Association of Colleges of Nursing (AACN) is encouraging their advanced nurse practitioners (NPs) to obtain a doctoral degree called the “doctor of nursing practice” or DNP, she added. From 2009 to 2010, the number of students enrolled in DNP programs rose from 5,165 to 7,034. During the same time, the number of DNP graduates nearly doubled from 660 to 1,282, according to the AACN.

“We certainly encourage all providers to pursue their highest level of education,” said Dr. Cayce, who practices in Columbia. “It’s just that we want to make sure that they are clear about their certification.”

And it’s not just NPs. Optometrists, physical therapists, and podiatrists are all being addressed as “doctor,” Chandra said.

Patient awareness

According to an American Medical Association (AMA) survey of the public published in 2010, nearly half of the respondents — 44 percent — had trouble distinguishing between licensed medical doctors and other health care providers based on the services they offered, their title and other licensing credentials. While 35 percent of patients believe that a nurse with a DNP is a medical doctor, 54 percent believe an optometrist is too. (In comparison, 84 percent of respondents knew that dermatologists were medical doctors.)

“Gone are the days when just physicians provided health care. Today, there is a wide array of individuals on the front lines of outpatient care,” noted Martin Cohn, associate director of the Massachusetts Academy of Dermatology. “The patient sees someone in a lab coat or scrubs and thinks he or she is a doctor.”

The number of health care providers offering services will continue to increase primarily because of the need to expand access to health care delivery, especially with regard to maintenance of chronic health conditions, and in light of health system reform that could add millions of people to the system, said Michael Zanolli, MD, a dermatologist in Nashville, Tenn. Moving forward, health care will require more of a team approach. Patients should know which team member is providing their care and what level of training that individual has, he said, and pointed out that the type of training differs between, for example, physician assistants (PAs) and NPs. Patients going into a medical office need to know if Dr. X is a physician, nurse, or neither, he added.

Often, patients in a health care setting are too anxious or intimidated to ask about a provider’s training and credentials, said Bruce Brod, MD, Pennsylvania dermatologist and chair of the AADA’s State Policy Committee. He believes that a team approach will increase access to health care, which is a positive outcome. “But the team should still be led by physicians with full disclosure to the public as to which member of the team is providing care at that time,” he said.

That is where legislation comes in. “It will bring awareness to patients so that they can make informed decisions,” said Mary Finnegan, MD, president of the Nebraska Dermatology Society. In fact, 87 percent of respondents to the AMA survey supported state legislation calling for transparency in all health care advertising materials.

Arizona, California, Colorado, Illinois, Maryland, Mississippi, and Pennsylvania are among the handful of states that already have such laws. In 2011, laws were enacted in Connecticut, Oregon, Tennessee, Louisiana, and Utah. The AADA supported truth in advertising legislation in 11 states last year and anticipates legislation to be introduced in several states in 2012, Chandra said. [pagebreak]

Truth in advertising

States are using one of two approaches. They are requiring truth in advertising and/or the wearing of identification (ID) badges. For example, in states such as Arizona and California, laws require advertisements for medical services to include a health care provider’s title and licensure. In Louisiana, physicians who use the term “board certified” can do so only after meeting very specific criteria and by stating the full name of the approved medical specialty certifying board, Dr. Massengale explained. Several members of the Louisiana Dermatologic Society partnered with the Louisiana Society of Plastic Surgeons to hire a lobbyist to get the bill passed, he said.

In 2010, a similar bill was introduced in Minnesota. This one specified advertisements to include billboards, brochures, pamphlets, radio and television scripts, electronic media, printed telephone directories, telephone and direct mail solicitations, and any other means of promotion. The second part of the bill required patients who want to undergo an elective cosmetic surgery to be seen by a physician prior to the procedure. The Minnesota Dermatologic Society believes that patients who seek these procedures should be evaluated by a physician to ensure that the patient is accurately diagnosed and recommended to have an appropriate procedure as well as to ensure that, for example, malignancies or underlying endocrinopathies are not missed, Dr. Smith said. The society is working with the American Society for Dermatologic Surgery Association and speaking with legislators about reintroducing the issue this year. The AADA has been supporting their joint efforts on this issue.

A public hearing on a truth in advertising bill introduced last year in Massachusetts was held before the Joint Committee on Public Health, but that is where the bill remains. The Massachusetts Academy of Dermatology not only provided testimony, but also gave the committee information about the success of the Pennsylvania law, Cohn said.

ID badges

Other states have tackled this issue by focusing on ID badges. For example, Connecticut legislation requires health care providers to display photographic ID badges during work hours while Illinois mandates they wear clearly visible name badges stating their credentials.

In Pennsylvania, health care providers must wear a photographic ID badge that indicates their license or certification in a font that is larger than the provider’s name and degree. The letters must be visible from a normal distance and, more importantly, the degree spelled out, not abbreviated, said Dr. Brod, who practices in Lancaster. The Healthcare Provider ID Badge Bill, which became law in December 2010, was directed at outpatient facilities as providers in hospitals there typically already wear ID badges that indicate their level of licensure, he noted.

In Missouri, the ID badge bill targeted those worn by hospital personnel, but Dr. Cayce would like to see it move to outpatient centers. “The greatest confusion here is in large health care settings, such as hospitals, where physicians, nurses, and physician assistants all walk around dressed alike,” she said. The bill did not make it to the governor’s desk primarily due to cost concerns on the hospitals’ behalf, said Dr. Cayce, but it will be re-introduced this year.[pagebreak]

The bill that was pending in New Jersey in December would have required that providers disclose their name, type of license, and highest level of academic degree to patients and in all advertisements. Physicians would also have to say if they are a board-certified specialist and provide the name of the board that certified them, if any, during in-office visits, explained Alexander Doctoroff, DO, the Dermatological Society of New Jersey’s immediate past president. “I would have preferred that the bill be more transparent, like the Pennsylvania bill, but it is a step in the right direction,” he said. The bill may be reintroduced at some point in 2012.

Tennessee laws address both issues. The law requires health care providers to communicate the type of license they hold by posting a sign at the entrance to their office that contains their name and degree. In outpatient settings, such providers must wear a photo ID that includes their name and type of license. A nurse, for example, must specify if he/she is a licensed practical nurse, a registered nurse, or an NP, said Dr. Zanolli, who serves on the Board of Trustees of the Tennessee Medical Association and helped write a resolution that served as the basis for this legislation. Those who provide information online must disclose their name and type of license, as well.

In Nebraska, the state dermatology society is working with the National Academy of Eye Physicians and Surgeons to obtain the support of the Nebraska Medical Association for truth in advertising/medicine legislation that will address full disclosure in advertising and on ID badges. If this resolution passes, Dr. Finnegan said it will then be worked into a bill, which they hope to introduce this year.

“The importance of legislation is to get a standard for advertising so that it is done ethically and meets certain guidelines in terms of accuracy in displaying board certification and degree of licensure, and not abusing the term doctor,’” Dr. Brod said. In addition to legislation, the public must be educated through media campaigns that explain who a dermatologist is and, for example, the difference between a dermatologist and a cosmetologist, he said.

“Patients make complicated decisions regarding their own health care and the health care of their loved ones each and every day,” Cohn added. “They have the right to know the credentials and the level of training of that person making the important diagnosis, pushing medications into that intravenous line, holding the scalpel, and pointing the laser at their face.”

Academy offers members help in fight for truth in advertising

Dermatologists who want to join the effort to ensure that patients know who they are seeing can turn to the Academy for help. The Academy’s online Advocacy Toolkit, available at www.aad.org/member-tools-and-benefits/aada-advocacy/state-affairs/advocacy-toolkit, provides members with the facts regarding truth in advertising, as well as documents for use in meeting with state legislators about the issue. Templates for communicating with the media about the issue are also available.

Dermatologists who want to join the effort to ensure that patients know who they are seeing can turn to the Academy for help. The Academy’s online Advocacy Toolkit, available at www.aad.org/member-tools-and-benefits/aada-advocacy/state-affairs/advocacy-toolkit, provides members with the facts regarding truth in advertising, as well as documents for use in meeting with state legislators about the issue. Templates for communicating with the media about the issue are also available.